The patient is an adult 66 years old with history of CABG and angioplasties (renal and carotid) with mild Pulmonary arterial hypertension. Edema present in both ankles and feet.
Hi Priya: The recent treatment algorithm was published in JACC recently
http://www.ncbi.nlm.nih.gov/pubmed/24355643
Rehabilitation is also crucial to his well-being
The most important parameter in this pt is LVEF. In case of depressed LVEF, optimised antifailure management i.e. B blockers, diuretics, ACE inhibitors, aldactone, etc. The edema can be related to LV dysfunction. Adding sildenafil in this pt for PH acn be dangerous if he/she is already on nitrates.
Dear Priya, this patient has most likely "Pulmonary hypertension due to left heart disease" not "Pulmonary arterial hypertension". This differentiation is key, because treatment is completely different for these two types of PH. How high is mPAWP or LVEDP in your patient? How high is the gradient between diastolic PA pressure and mPAWP? In case of high mPAWP heart failure medication is recommended (optimisation of LV function). There is no robust data that supports the use of Sildenafil in such patients.
Dear Colleague,
I fully agree with the previous comments. Your patient is most likely suffering from Group 2 PH. If you plan a right heart catheterization, I suggest also to get a left cath with a LV telediastolic pressure, as suggested. If any doubt about pre or post capillairy, a fluid challenge and/or mild exercise haemodynamics will help you distinguish pre and post-capillary PH. PH diagnosis could be not as easy as planned for elderly patients with cardiovascular conditions...
Kind regards.
FL
Next week in Barcelona new ESC guidelines will be published for pulmonary embolism. To be published in the EHJ very soon.
Otherwise I would confirm the excellent thematic issue published in JACC in December 2013, including several outstanding state-of-the-art lectures.
Best wishes,
Thierry
I presume the finding of " mild PAH" is based on echocardiographic measurements. Before getting carried away with esoteric and invasive measures, first start with this. Is the LV impaired/dilated? Also, what about RV size and function? If you have some measure of LV dysfunction, the elevation of sPAP is modest and there is no RV dysfunction or dilatation then you are really going to add nothing with invasive haemodynamic measures; it's left heart disease and its consequences which needs to be treated as such. You really only need to persue this if there are right sided changes which clearly disporportionate to changes in the LV on echo.
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